Sometimes I've Believed as Many as Six Impossible Things Before Breakfast

The biggest threat to ICU? – Intensivists.

We are the biggest threat to the ICU; doctors, intensivists, the people that do our job.

Intensive care is the greatest specialty in medicine. Sure, I am biased, but I am allowed to be and really you should be excited about that, you should be grateful. There are of trainees up and down the country who, like me, apply for intensive care because they have a passion, because they want to be great single specialty intensivists. What do we say to these people?

We say ‘and what else will you do?’.

We say ‘when are you going to think about your second specialty?’

Sometimes we say ‘but you’ll never have the skills of an anaesthetist’ and often we say ‘it’s prudent to have a second string to your bow’.

If you’re a trainee and you haven’t heard that last phrase from a supervisor or mentor, I am surprised. But what does it mean? To have a ‘second string to your bow’. It is of course a phrase originating from archery and makes reference to having a second string incase the first one breaks. It is a back-up; the second string was never meant to be used at the same time as the first. A single, strong, resistant thread is what makes a bow effective.

This is not an argument against dual training. It is an argument that dual training is not the answer to burnout and it is not the right answer for everyone. It is an argument that wonders why we nurture so readily the expectation that you won’t ‘just’ CCT in ITU? Yes, we have created stand-alone ICM training, but are we actually encouraging it to stand alone?

Intensive care already has the benefit of drawing its trainees from different streams of core training and special interests will of course always be of value at both an individual and departmental level. There are however a myriad of interests and skills which can be developed and maintained outside of formal dual accreditation.

People will talk about job plans, they say ‘you know the reality is…’ They’re not wrong, job plans matter and remain a stumbling blog for a number of acute specialties. The Royal College of Emergency Medicine report ‘Stretched to the Limit’ found that 62% of current job plans were felt unsustainable by emergency medicine consultants and when asked what would support more sustainable working within their specialty the number one suggestion was to actually change the job plans (1). Job plans are a reality that we created and we are the ones who ultimately have the power to drive the change that is needed.

Instead, we take trainees who want to be full-time intensivists and immediately instill in them a worry that there might not be job security with a single specialty. As one of those trainees, it feels like a ‘computer says no’ attitude and the future of intensive care is surely more important than that?

People will talk about the mental toll, they will say ‘you know the reality is…’ and again they’re not wrong. There is an emotional toll to be paid of course, but when we insist this is absolutely unique to our specialty, we flatter ourselves. There are huge challenges to be met, but we are the ones with the power to make intensive care the most well supported specialty in medicine. Other specialties already do it much better and saying ‘it’s just too much, you have to do something else’ is an indulgence, it is a cop-out and it is not an answer.

In 2002, a survey of all intensive care society members currently working in intensive care found that 29% of respondents had signs of psychiatric morbidity, but the level of mental health problems was not associated with age or long hours of work(2). They did however highlight that many important stressors that were identified could be modified by improved team work and resources. As a trainee, I am repeatedly ‘warned’ that stand-alone training is not sustainable because the hours are too long and ‘nobody wants to be doing that when they get older’. I am repeatedly advised that stand-alone training will lead to burn out and that dual accreditation is the answer. The truth is, there are no large randomized controlled trails that have examined strategies to counteract the phenomenon of burnout in intensive care doctors.

So yes, the future of intensive care is under threat, but its stands with an army of trainees, some of whom want to be single specialists. What sort of leader, recognizing that, would tell its soldiers ‘no, just give me 50% of your commitment, passion and drive’ and how can we expect victory in battle when we are so ready to tell our soldiers to just accept that the end goal, the career, is de facto not sustainable?

Intensive care could, I think, be the greatest stand-alone career in medicine, but until we are willing to support and create that reality; we are the biggest threat to the future of the ICU.

Listen to an audio of this blog and subsequent roundtable discussion – via ICN Podcasts

Thanks Danny for your comments – I don’t disagree with you, as we say, ICU is under threat and that is certainly the buzz word. I think what my point is that I really find it impossible to believe that the the problem of burnout can not be fixed, alleivated, counterbalanced with the right sort of thinking. But it would have to be a revolution, of course.
I’m not knocking the idea of dual specialitie, it is a valid choice and the right one for lots of people but I simply don’t believe that a ‘back up’ is the answer to the problems facing the future of ITU.

We should fix the problems causing burn-out and stop putting ineffective plasters over them.. retaining as much passion as is on offer from all ICM trainees who the speciality is what’s in the long term best interests of the speciality surely.